Rebuttal: Should family physicians assess fitness to drive?

Assessment of patients’ fitness to drive is an important societal role for family physicians. My colleague, Dr Laycock, argues 2 points regarding a family physician’s role in assessment: He suggests that physician evaluation in an office setting is inadequate and that assessment of safe driving does not require physician-specific skills. I would argue against both of these statements and suggest that, in fact, it is imperative that physicians participate in the evaluation of driver fitness. The assertion that driver fitness is a “non-medical” determination is not justified based on the current literature.

A Clinical Review on fitness to drive in patients with cardiac and cognitive conditions was published last month in Canadian Family Physician.1 It proposes organizing a patient’s medical conditions into “acute intermittent” and “chronic persistent.” Such classifications require medical knowledge and “acute intermittent” conditions require an estimation of probability of recurrence. These are decisions that must be made by a physician. As we know, there are medical problems that can suddenly incapacitate an otherwise low-risk driver, and a non-medical assessor would lack the knowledge to realize these substantial risks.

Dr Laycock suggests that “other than for determining absolute disqualifying diagnoses, the current physician-based paradigm should be set aside and simulated road testing or on-road testing should be established.” I believe there are 2 issues here that are important. One is the cost of specialized, comprehensive on-road tests, which can vary from $50 to $800 and is currently the patient’s responsibility to pay.1 There is no doubt that these assessments are useful, but family physicians can play an important role in screening patients with SIMARD MD,2 or approaches like the one presented by Molnar and Simpson,1 to determine who needs to undergo such a costly evaluation. Second, an occupational therapist or non-medical professional performing a 1-time simulated or on-road test might have limited understanding of the medical risks or potential stability of patients’ medical conditions. A patient might perform well on a functional-abilities driving test one day and decompensate days or weeks later.

Dr Laycock correctly points out that “good cognitive ability is the foundation of competent driving.” With the aging Canadian population, it continues to be essential that family physicians are competent in diagnosing cognitive impairment. Dementia guidelines3 have been available since 1998, and patients with mild to moderate forms of the disease will visit family physicians first and will be cared for primarily by their families and primary care physicians.4 One of the recommendations from the most recent Canadian Consensus Conference on the Diagnosis and Treatment of Dementia in 2006 states that “most patients with dementia can be assessed and managed adequately by their primary care physicians.”5 In 2010, with the clinical tools1,6 we now have for screening cognitively impaired drivers, management must include evaluation of driving fitness. One could argue that physician remuneration for driving assessments needs to be addressed more formally, as the time to do such evaluations should be adequately compensated. Furthermore, it will be important that we have legal protection for our clinical decisions regarding driver fitness if these tools are used.

Family physicians have the expertise to work as part of a team to assess driver fitness. We should ensure that we include a driving history for all patients. Documentation of the driving habits of patients older than 65 years of age is especially important. We now have tools and clinical approaches to assist us with evaluating our patients, and if concerns or complexities are beyond our scope of knowledge, referral for on-road testing is available. We should not be passing this responsibility to non-medical professionals, as to do so would be detrimental to our patients’ safety.

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